It seems like every week another woman I follow online is talking about being newly diagnosed with attention-deficit hyperactivity disorder (ADHD). Some might call it a new fad, but one possible reason more and more adult women are being diagnosed with ADHD may be due to a history of underdiagnosis in girls. ADHD has historically been viewed as more of a boys’ disorder, because symptoms often present differently—and less obviously—in girls.
With the rise in ADHD diagnoses in women, how might ADHD interact with a woman’s hormonal health? This article will look in particular at premenstrual dysphoric disorder (PMDD) and its relationship with ADHD. We will also examine the connection between PMDD and autism, another disorder that is being increasingly diagnosed in women after historically being more predominantly diagnosed in boys (and, then, men).
So, what is PMDD? How is it related to autism and ADHD? How strong is the research evidence suggesting these relationships? And what’s the impact on how PMDD is treated? Let’s dive into these questions.
What Is PMDD?
Premenstrual dysphoric disorder (PMDD) can be considered a “more extreme cousin” of premenstrual syndrome (PMS). Affecting up to 2% of women, PMDD can begin after ovulation (during the luteal phase) and last through the first few days of a woman’s period. Like PMS, its most common symptoms include fatigue, bloating, irritability, depression, and anxiety. Unlike PMS, its symptoms are so debilitating that they significantly impair a woman’s daily functioning. PMDD is also considered a depressive disorder by the American Psychiatric Association.
PMDD is often treated with diet changes, regular exercise, stress management, vitamin supplements, anti-inflammatory medicines, selective serotonin reuptake inhibitors (SSRIs—a type of antidepressant), and/or hormonal birth control.
What Is ADHD?
Usually diagnosed in childhood, attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder. People usually have one of three types:
- Predominantly inattentive presentation, which is characterized by difficulty planning or completing a task, paying attention to details, or following instructions. People with this type of ADHD are also typically easily distracted or frequently forget the details of daily routines.
- Predominantly hyperactive-impulsive presentation, which is characterized by being fidgety or talking a lot, having a hard time sitting still, restlessness, and impulsivity.
- Combined presentation, which is characterized by having some symptoms of both of the other presentations.
ADHD is often treated with a combination of medication (particularly stimulants, like Adderall) and behavioral therapy, including strategies to help cope with symptoms.
PMDD and ADHD
Women with ADHD are at higher risk of mood disorders, and a 2021 study found that women with ADHD were significantly more likely to have PMDD (and, interestingly, postpartum depression) than women in the general population [1]. (Now, this was the first study of its kind, so keep in mind that research on the topic is still in its early days.)
Why might women with ADHD be more likely to have PMDD and/or postpartum depression? We know that hormones affect far more than ovulation and menstruation, impacting every part of the body. As a result, it’s unsurprising that hormones like estrogen and progesterone interact with some of the same parts of the nervous system that play a role in ADHD, as this article by Dr. Dora Wynchank (a psychiatrist who specializes in ADHD) notes. Estrogen promotes serotonin and dopamine, which causes a reduction in ADHD symptoms. As a result, during the part of their cycle when estrogen is high (the follicular phase), women with ADHD may find that their ADHD is easier to manage.
Furthermore, Dr. Wynchank writes, the fluctuating levels of estrogen throughout the cycle may impact the effectiveness of a stimulant prescribed to help a woman manage her ADHD symptoms. She cites a few small studies finding that estrogen enhances the impact of the stimulant medication, while progesterone decreases it. As a result, while the stimulant may be particularly effective during the follicular phase, it may be less effective during the luteal phase, when progesterone is dominant. (More on stimulants below!)
What about PMDD and Autism?
Autism spectrum disorder (ASD) is a developmental disability whose symptoms include difficulties with social communication, restricted interests, and repetitive behavior. True to its name, these symptoms exist on a wide spectrum, and someone with ASD may be severely impaired or have relatively little impairment.
According to the British National Autistic Society, there is not a lot of research into the interplay between women’s hormones and autism. In an article on the Society’s website, Dr. Annabeth Groenman, a postdoctoral researcher at the University of Amsterdam, writes that this dearth of research is because autism research has until recently focused on autism in children and adult men.
Just how prevalent is PMDD among women with autism?
Dr. Groenman cites two studies that report a huge discrepancy in prevalence rates of PMDD among autistic women. In a 2008 study of just 26 women with autism and learning disability, 92% of autistic women experienced PMDD compared to 11% in the control group [2]. Of course, this is a very small sample size and does not include autistic women without learning disability. On the other end of the spectrum, Dr. Groenman also cites a 2016 study that found that only 21% of autistic women experienced PMDD [3]
To advance this research, Dr. Groenman and colleagues published a study in 2021 looking at both PMDD and “menopausal complaints” among autistic women [4]. This study, which had a slightly smaller sample size, found that 14.3% of autistic women and 9.5% of non-autistic women met criteria for PMDD—a non-statistically significant difference. Still, Dr. Groenman writes in her article for the National Autistic Society, “Reported prevalence rates vary so immensely (14.5%–92%) that it does appear that PMDD is something that autistic people who menstruate should be aware of.”
I’d add, like I frequently do in my articles for Natural Womanhood, that we need more research on this topic!
Treating PMDD and ADHD or autism when you have both
What special considerations are warranted for women with PMDD and ADHD? Dr. Dora Wynchank notes that hormones impact the effectiveness of commonly-prescribed stimulants like Adderall. In particular, as we noted earlier, the rise and fall of estrogen and progesterone throughout a woman’s cycle influences the effect of the stimulant.
The 2021 study on women and ADHD concluded that “Existing treatments consist of antidepressants, contraceptives or hormonal suppletion therapy … A temporary increase of the stimulant medication dosage during the premenstrual week, or light therapy in the last week of the menstrual cycle may as well be helpful for women with ADHD. However, studies on the efficacy of such treatments are still lacking” [1].
There seems to be a lack of research on treating PMDD in autistic women as well. At the very least, if you have both autism and PMDD, be sure to talk to your gynecologist or general provider about any prescriptions you already take and how those may interact with their treatment plan for your PMDD.
Are there alternatives to hormonal birth control as a treatment for PMDD in women with ADHD or autism?
Hormonal birth control is also frequently recommended as treatment for PMDD. As we’ve noted elsewhere, however, birth control comes with some drawbacks. For example, hormonal birth control has a laundry list of potential side effects, some of which mimic PMDD symptoms! What’s more, hormonal birth control shuts down the menstrual cycle and its many whole-body health benefits, which we highlighted in our Reasons Women Need Periods series.
How FAMs can help women with PMDD and autism or ADHD
Any woman can benefit from learning to chart her cycle through a fertility awareness method (FAM), perhaps most especially women who suffer from mood disorders. This article shows just how impactful cycle mindfulness education, achieved through fertility awareness method charting, can be for teen girls with troubled pasts and, possibly, undiagnosed PMDD. FAM use can be a great complement to other conventional treatments for PMDD, including antidepressants and/or diet and lifestyle changes. For women with ADHD, there is another benefit. When they can track how their symptoms fluctuate throughout their cycles, women with ADHD may choose to work with their healthcare provider to adjust their stimulant dosage for optimal results.
References:
[1] Dorani, Farangis et al. “Prevalence of hormone-related mood disorder symptoms in women with ADHD.” Journal of psychiatric research vol. 133 (2021): 10-15. doi:10.1016/j.jpsychires.2020.12.005 [2] Obaydi H, Puri B. Prevalence of Premenstrual Syndrome in Autism: A Prospective Observer-rated Study. Journal of International Medical Research. 2008;36(2):268-272. doi:10.1177/147323000803600208 [3] Lever, A.G., Geurts, H.M. Psychiatric Co-occurring Symptoms and Disorders in Young, Middle-Aged, and Older Adults with Autism Spectrum Disorder. J Autism Dev Disord 46, 1916–1930 (2016). https://doi.org/10.1007/s10803-016-2722-8 [4] Groenman AP, Torenvliet C, Radhoe TA, Agelink van Rentergem JA, Geurts HM. Menstruation and menopause in autistic adults: Periods of importance? Autism. 2022 Aug;26(6):1563-1572. doi: 10.1177/13623613211059721. Epub 2021 Nov 26. PMID: 34825585; PMCID: PMC9344571.Additional Reading:
Cycle mindfulness: what happens when you teach fertility awareness to teen girls
